Welcome to today’s coffee break presented by the Evaluation and Program Effectiveness

Team and the Division for Heart Disease and Stroke Prevention at the Centers for Disease

Control and Prevention. We are fortunate to have Alberta Mirambeau as today’s presenter.

Alberta is a health scientist on the Evaluation and Program Effectiveness Team. My name is

Martha Bose and I am today’s moderator. I am an Evaluation Fellow here on the same

team as Alberta. Today Alberta will be presenting on how to conduct a cost analysis.

*Note: Screen magnification settings may affect document appearance.

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Just to give you a quick overview, today I’ll be talking about conducting a cost analysis and

sharing some key principles related to conducting a cost analysis. Then I’ll walk through an

example. I’ll close with a few remarks for your consideration and then share some tools

and resources that you can reference after this presentation.

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Before we actually talk about conducting a cost analysis I want to pause and talk about the

purpose of economic evaluation. Economic evaluation in public health programs focuses

on the resources used to implement a program or intervention and the health impacts of

that program.

Using the simplified logic model before you, economic evaluation focuses on the resources

and inputs and then factors changes in health outcomes so that decision makers are able to

use it as a tool to make choices and comparisons about whether the outcomes yielded

from a program are worth the resources used to produce those results. There are various

types of techniques when applying economic evaluation. There is a cost analysis, cost

benefit analysis, and cost effectiveness analysis among many others. Obviously today I’ll be

spending more time on conducting a cost analysis.

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Let’s start by defining a cost analysis. Borrowing from the earlier image, we see that the

cost analysis focuses primarily on the inputs and resources and it doesn’t yet factor the

outcomes of a program so inherently the emphasis of a cost analysis is on the costs.

Therefore, conducting a cost analysis is the first step to applying any economic evaluation

to your program. It’s also beneficial to conduct a cost analysis when truly answering the

question: how much does it cost to implement program or intervention X?

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Here are a few key concepts related to cost analyses. With any evaluation you want to start with a

purpose and a plan and this point is ideal to seek the consultation and services of a health economist.

While the expertise of an economist will be needed for a majority of your economic evaluation efforts

or the more advanced analyses it’s still important to be very involved as a program administrator, so

that you’re much more informed and prepared to undergo a cost analysis by understanding a few key

principles.

One of those principles has to do with which costs are counted or in other words from whose

perspective? Everyone has a cost to pay so there are a few perspectives to consider when determining

those costs. Think about the pubic health system perspective, which used when you are looking at how

much funding the public health system needs to just start up and operate a program. Another example

is the insurer perspective and in this case they are most interested in the cost incurred through claims

or reimbursements. Whereas the societal perspective looks at costs incurred by all parties and this is

the most common perspective.

So let’s say you’re responsible for implementing a YMCA lifestyle modification program. From the

societal perspective the health insurance, if a health insurance agency is also partially funding that

program have a cost. The YMCA has also has costs—maybe for the facilities or for employee time; Even

if the program is free, the participants may have a cost whether through transportation costs, time lost

from work or daycare expenses. The societal perspective accounts for all of these hidden costs incurred

by someone in society.

Another point I want to mention about conducting a cost analysis is the timeline in which you do it. If

you are collecting the data while the program is being implemented then the costs are being captured

prospectively. If the program period has already taken place and you’re looking at costs after the fact

then that’s a retrospective approach. Assessing costs prospectively is ideal because it allows for a more

systematic and accurate data collection process.

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On this slide are a few key terms and in essence when we’re talking about conducting a

cost analysis we are operationalizing resources, which translates into the workforce,

workspace, et cetera. These can then be itemized through your cost categories. It is

through the development of the cost categories you start to determine which costs you are

going to count in your cost analysis. Then you consider the costs or the value of those

resources.

We can then go a step further with costs by looking at them in two ways: financial or

economic. Financial costs refers to what commonly comes to mind when we think of costs,

such as the market value or the price tag of a resource. The financial costs of running a

program are more easily identified in a budget sheet. On the other hand, economic costs

are those costs that do exist but there may not be a direct exchange of funding so I refer to

these as your hidden costs. For example, just because the time of a volunteer is not

reflected in a budget sheet doesn’t mean that there isn't a monetary value for their time.

Although the financial costs are a convenient source for conducting a cost analysis they also

give an incomplete picture of the resources that it takes to implement a program. If there

is a resource that is needed to implement a program then that cost should also be

accounted for and when you account for both financial and economic costs, you are

strengthening the accuracy and credibility of your economic analysis.

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A cost analysis is the first step to applying economic evaluation to your program and it’s

important to understand that a sound economic evaluation stems from a sound cost

analysis. It is simply the first step.

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Now we can actually go into the example. Today I’ll be talking a bit about the steps that we

use for conducting a cost analysis of a community health worker program. This is just one

approach and one method to conducting a cost analysis and it is not to be implied as the

only way to do so.

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On this slide I lay out the major steps that we took in this process and bolded the steps that

I think are most important to remember when conducting your own cost analysis; the other

steps are ideal but not necessary. I will walk through each step in the next few slides.

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As I mentioned before, with program evaluation or economic evaluation you always want

to define the purpose and the scope. In this instance, we wanted to articulate the full range

of cost for this program and this helped us define what the project was and what it wasn’t

and right away we were able to see what our limitations would be.

We decided that the cost analysis would be based on just the community health worker

program component, which is part of a much larger program; and we were going to do it

retrospectively and look at a one year period. We also decided to use the public health

system perspective—meaning we weren't going to account for other costs such as those

incurred by the participants or insurance companies.

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The second step that we took was a literature scan. We conducted a literature scan and

assessment and in essence you can translate this into doing your homework. This helped us

to really understand what other programs have done in the literature and how they did it.

We determined which studies were relevant to our particular program and what ideas we

could borrow from cost analyses that were conducted previously.

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After that, we developed the cost categories. This picture shows the series of steps that we

took. We used information from the literature scan, looked at other cost analysis tools,

reviewed program documents, and dialogued with the program staff. With each step there

was a different version of the cost categories as we identified what data were and were not

available. This process was certainly an iterative process and should be reflective of your

program.

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On this slide are the items that we actually identified as our cost categories. I don’t expect

you to be able to read every detail on this chart; we’ll have these slides available on our

website for you to review at your own leisure. What I’d like to emphasize here is that the

cost categories that you eventually land on should be reflective of your program.

Let’s say, for instance, the lifestyle interventions of the WISEWOMAN program differs from

state to state; therefore, one would expect that while they are all working to accomplish

similar goals, their program and therefore their costs are different. So you will want to

ensure that your cost categories are reflective of your program’s particular setting and

activities.

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In our cost analysis we also conducted a time study and this helped us to be able to look at

how the community health workers were allocating their time to specific activities. Now, it

is not an essential step but it is ideal because this activity enabled us to have another layer

of information on how costs were being expended and used in terms of the community

health worker’s time.

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Once you have done all these different activities, then you want to actually collect the data.

When possible, we used original data source and used industry standards for the economic

costs. Industry standards were used for items such as volunteer time and workspace.

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Then, lastly, you calculate your costs. I have noted here that we conducted a sensitivity

analysis as part of our endeavor and this helped us to look at different scenarios from the

least expensive program scenario to the most expensive program setting for implementing

the program.

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In summary, here are a few things that I’d like to share with you that we learned from this

process of conducting a cost analysis:

• You definitely want to be systematic and thorough when identifying your cost categories

and ensuring that they reflect your particular program.

• Remember to consider variables that may not be reflected in your budget, such as in-

kind support, volunteer time

• And when possible use original or actual data sources.

While most decision makers are most interested in the benefit or results of program costs,

which is usually provided through cost effectiveness or cost benefit analysis, it remains

essential that cost analyses are conducted with accuracy and a degree of rigor. And most

importantly, that they are considered as the first step to any type of economic evaluation.

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Here are a few tools and resources for your review and for referencing information related

to economic evaluation. The first items listed served as the primary resource from which I

referenced a majority of the information shared in the earlier parts of this presentation.

The 5-part podcast can be found on our Division web-site and provides a module

specifically on conducting a cost analysis. The other resources should also serve you well

for learning more about economic evaluation.

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Question 1: You mentioned that you recognize the limitations of the project. Could you elaborate on

what those limitations were?

Response: When we started to determine the scope of the project and what was feasible to do we

realized that by doing it retrospectively rather than prospectively we were going to be limited in the

data that were going to be available to us; right away, that’s a limitation. We also limited the project

scope to just one year. The program has been in existence for over three years and an ideal situation

would be to look at those entire three-year periods and to come up with an average of the costs—that

way we have a more realistic understanding of the costs rather than just relying on one year. As we all

know with the market and how costs fluctuate, an analysis of all three years would have provided a

much more accurate and comprehensive understanding of the costs. And obviously the cost analysis

was just for this one setting so we don’t have any group to compare or another program that is similar in

scope and context to compare the costs to; that also adds another limitation to the project.

Question 2: What were the benefits of adding a time study to the cost analysis?

Response: It allowed us to look at the distribution of time that the community health workers were

devoting to certain activities. Therefore, not only were we able to know what proportion of the costs are

committed to documenting activities or what proportion of the costs are committed to direct patient

support; we were also able to see the reach. It was another way of looking at how often and to what

extent the community health workers were coming in contact with individuals. It also allowed us to look

at the time and scope of activities of the volunteers and not just the community health workers. This

way we had an idea of not only of what the volunteers do but how they were contributing to the

community health workers’ activity. Thus, there were a few benefits for adding that component.

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If anyone thinks of additional questions or topics related to economic evaluation or ways

you would like to receive more TA about economic evaluation please feel free to email us at

the address listed on the slide.

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